Dr Douglas Bettcher Director, Prevention of Noncommunicable Diseases (PND) World Health Organization The 10th APACT Conference, Chiba, Japan

FIGHTING NONCOMMUNICABLE DISEASES (NCDS) TOGETHER WITH OTHER HEALTH PROBLEMS

Outline Noncommunicable diseases (NCDs) as the new frontier of public health

NCDs, communicable diseases (CDs), and social determinants of health

Global action and multisectoral engagement

NCDs and the post-2015 development agenda

I Why are NCDs the new frontier in the fight to

improve public health?

An epidemiological transition is positioning NCDs as the largest global disease burden, disproportionately affecting developing countries.

1990 - 2010

An epidemiological transition globally is shifting the primary health challenge from communicable to noncommunicable diseases

Maternal mortality decreased from 400 deaths per 100,000 live births to 210 deaths per 100,000 live births

Under-five morality rate decreased from 87 per 1,000 live births to 53 per 1,000 live births

Life expectancy at birth increased from 62 years to 68 years

Present

63% of deaths due to NCDs

Projected 30% of all deaths in 2015 due to CVDs

1.3 million annual deaths attributable to diabetes

Sources: UNICEF, WHO

Projected 17% of all deaths in 2015 due to cancers

Unhealthy diets

Tobacco

Harmful use of alcohol

Physical inactivity

Risk factors

Noncommunicable diseases and conditions

Chronic respiratory

diseases

Cardiovascular disease

Diabetes

Cancer

Mental disorders

Injuries

Tobacco and noncommunicable diseases (NCDs): 4 risk factors, 4 NCDs, 2 conditions

16%

47%

9%

17%

Global deaths (2008)

Deaths in developing countries only (2008)

10%

42%

31%

28%

Communicable diseases, maternal, perinatal and nutritional conditions NCDs after the age of 60

Injuries

Of the 57 million global deaths in 2008, 36 million or 63% were due to NCDs

NCDs before the age of 60

In all regions except Africa, NCD-attributable mortality has exceeded mortality due to communicable diseases

Source: WHO Global Burden of Disease Report, 2004

NCDs are projected to rise in the next two decades, and the burden is expected to fall disproportionately on developing countries

Projected increase in NCD-related deaths worldwide in the next 10 years:

17%

Low-income countries face a double burden of NCDs

Sources: WHO; Science, 2012

How are NCDs related to development,

communicable diseases, and social determinants of health?

NCDs have tremendous socioeconomic impacts, undermine development agendas, and share common risk factors with other health problems.

A rapidly rising epidemic in developed and developing countries …

… with serious socio-economic impacts, particularly in developing countries

Workable solutions exist to prevent most premature deaths from NCDs and mitigate the negative impact on development.

The way forward: these solutions need to be mainstreamed into socio-economic development programmes and poverty alleviation strategies

UN Secretary-General: NCDs in developing countries are hidden, misunderstood and underrecorded

• Poverty: Household income is spent on health care for NCDs, medicines, tobacco and alcohol use

• Hunger: Underweight children and overweight adults are often found in the same households

• Maternal health: Malnutrition increases the risk of gestational diabetes and poor maternal health

• Child health: Malnutrition in pregnancy is associated with a vulnerability to obesity, cardiovascular disease and diabetes later in life

• Education: NCD-related costs displace household resources for education

• HIV/AIDS: Increases the risk of cancers, and ARVs increase the risk of cardiovascular diseases

• Tuberculosis: Tobacco and alcohol use, and diabetes are associated with TB deaths

• Essential drugs: Cost-effective medicines to treat NCDs are available in low-cost generic forms, but remain inaccessible and unaffordable to most who need them

The poorest people in developing countries are affected the most: Example: NCDs undercut the attainment of the MDGs

• MDG 1 – Eradicate extreme poverty and hunger o 5.3 million hectares of arable land under tobacco

cultivation could be used to feed 10 to 20 million people

• MDG 2 – Achieve universal primary education o Tobacco industry uses children in cultivation and

production

o Some very poor families choose tobacco over education of their children

Tobacco, one of the leading risk factors for NCDs, has tremendous implications for the attainment of the Millennium Development Goals (MDGs)

• MDG 3 – Promote gender equality and empower women o Passive smoke disproportionately affects

women and children o Advertising encourages women in developing

countries to smoke as a sign of independence and success

• MDGs 4 & 5 – Reduce Child Mortality and

Improve Maternal Health o Women who use tobacco have smaller babies

who are weaker and more likely to die o Passive smoke increases respiratory and other

ailments in children

Tobacco and MDGS (2/4)

• MDG 7 – Ensure environmental sustainability – 200,000 hectares per year cleared for tobacco

farming and wood-fired curing – This causes 5% of deforestation in developing

countries, particularly among major tobacco producers such as China, Zimbabwe, and Malawi

– More than 2.5 billion kilograms of waste from tobacco manufacturing annually

• MDG 8 – Develop a global partnership for

development – Tobacco seriously threatens sustainable

development in the world’s poorest nations through: • disability and premature death (the double burden of

disease); • high personal and national economic costs; • environmental damage

Tobacco and MDGS (3/4)

• Smoking is detrimental for HIV patients o Tobacco is implicated in several

diseases such as bacterial pneumonia and AIDS-related dementia

• Smoking causes sub-clinical TB to

advance to clinical TB and possible death o 1 billion people may have sub-clinical

TB o In India, smoking causes 50% of TB

deaths

Tobacco most directly undermines MDG 6 – Combat HIV/AIDS, Malaria and Other Diseases, including tuberculosis (TB)

MDG 6

Tobacco use is an important modifiable risk factor for HIV patients at high risk of heart attacks

“Cigarette smoking is the most important modifiable cardiovascular risk factor among HIV-infected patients.”

“Cessation of smoking is more likely to reduce cardiovascular risk than either the choice of antiretroviral therapy or the use of any lipid-lowering therapy.

0

0.5

1

1.5

2

2.5

3

3.5

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Rat

e p

er

10

00

pat

ien

t-yr

s

Myocardial infarction Among Patients with HIV Infection

Sources: Holmberg et al. Trends in rates of myocardial infarction among patients with HIV, N Engl J Med 2004; 350:730-731; Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:48–62

TB is also linked to NCD risk factors including alcohol and tobacco use

More than 40% of global incidence of TB is attributed to active smoking, diabetes, and alcohol use

Of the four main NCD risk factors, tobacco use in particular has a tremendous impact on TB outcomes

Strengthen of evidence

Estimate of risk ratios

Outcome Exposure to tobacco

Limited 1.03 to 3.2 TB infection Active/passive

Strong 1.01 to 6.3 TB disease Active

Strong 1.6 to 9.3 TB disease Passive

Moderate 2.5 to 3.1 Recurrent TB Active

Limited 1.02 to 6.6 Mortality Active

The effects of tobacco use on TB outcomes are independent of the effects of alcohol use, SES, age, sex and other potential confounders. Source: WHO/The Union TB and Tobacco Monograph

High burden TB countries also have a high burden of tobacco use

More than 40% of smokers live in just 2 countries

Estimated new TB cases (all forms) per 100 000 population, 2007

No estimate

0-24

50-99

25-49

100-299

>= 300

Prevalence of tobacco use, 2005

• Smoking may attenuate mycobactericidal activities including oxidative stress in the lung tissues

• Mechanical disruption of cilia function and other clearance mechanisms in the tracheobronchial system

• Nicotine turns off the production of TNF-α by the macrophages in the lungs, decreasing the local levels of TNF-α in the lung might reactivate latent TB)

Source: Madhukar Pai, et al Expert Rev. Anti Infect. Ther. 2007, 5(3):385-391; 2.Davis PDO, et al Transactions of the Royal Society of Tropical Medicine and Hygiene.2006,100, 291—298

Possible mechanisms underlying the association between tobacco and

TB

Maternal

• Infertility/infecundity

• Preeclampsia

• Spontaneous abortion

• Ectopic pregnancy

• Placenta previa

• Placental abruption

• Premature rupture of membranes

Fetal and Neonatal

• Still births*

• Preterm birth* (< 37 wks)

• Congenital anomalies (cleft palate)

• Intrauterine growth retardation (IUGR)

• Low birth weight*

• Neonatal pneumonias

• Sudden Infant Death Syndrome

*Effects also noticed with use of smokeless tobacco during pregnancy

Among risk factors, smoking poses an especially dire threat to maternal

and child health

Maternal

• Exacerbation of existing maternal conditions affecting fetal and neonatal outcomes

Fetal and Neonatal

• Higher risk for stillbirth

• Higher risk for congenital malformation

• Reduction in mean birth weight by 33 g or more

• Increase LBW births (<2500 g)

• Sudden infant death syndrome (SIDS)

Indirect exposure to secondhand smoke also has dire consequences for

maternal and child health

Smoking prevalence (2004)

0

5

10

15

20

25

30

35

40

45

Low-income countries

Lower-middle

income countries

Upper middle-income countries

High-income countries

(pe

rce

nta

ge

)

Lowest household income quintiles

Highest household income quintiles

NCD risk factors: the poor tend to smoke the most

0

5 %

10

15

20

25

30

35

40

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Pe

rce

nta

ge o

be

se (

BM

I > 3

0)

Year

Female obesity (aged 16+ years) prevalence by social class 1997-2007: Health Survey for England

NCD risk factors: the poor in high-income countries are often at a greater risk of obesity

60 50 40 30 20 10

0 Catastrophic expenditures

Impoverishment

Cancer

No cancer

Percent with and without cancer experiencing in catastrophic spending and impoverishment (India)

pe

rce

nta

ge

NCDs: the poor are affected the most

Noncommunicable diseases

Morbidity, disabilities and premature death

Escalating health care costs. increasing financial burden in all countries

Populations in low- and middle-income countries

SOCIOECONOMIC LOSS

Loss of productivity

New perspectives

Globalization Urbanization Population ageing Poverty

NCDs reduce productivity and impede socioeconomic development

• Lost productivity due to tobacco-related

premature deaths:

$82 billion in the US and $2.4 billion in China per

annum • % of total health costs in high-income

countries due to tobacco-related illnesses:

6-15%

Tobacco use in particular has a tremendous macroeconomic cost

What are governments doing to scale up NCD

work at this juncture, and what are the roles of multisectoral stakeholders?

A global vision and affordable solutions exist to prevent 14 million people in developing countries from dying prematurely each year from NCDs

113 Member States

34 Presidents and Prime-Ministers

54 Vice-Presidents, Deputy Prime-

Ministers, Ministers of Foreign Affairs and

Health

100s of civil society

11 Heads of UN Agencies

1000+ news articles

The UN High-level Meeting on NCDs in numbers (New York, 19-20 September 2011)

2000

2003

2004

2008

Global Strategy for the Prevention and Control of Noncommunicable Diseases

Global Strategy on Diet,

Physical Activity and Health

Action Plan on the Global Strategy for the

Prevention and Control of NCDs

2010

2010

2011

Global Strategy to Reduce

the Harmful Use of Alcohol

WHO Global Status

Report on NCDs

Political Declaration on NCDs

2012+ Realizing the commitments made in the Political Declaration

WHO's leadership and coordination role in promoting and monitoring global action against NCDs

NCDs as priority within the development agenda

Whole-of-government approach to implement WHO's best buys on NCDs

Leading role of WHO in coordinating global action on NCDs

WHO to strengthen internal capacity to support Member States

Specific assignments that WHO has to deliver over the coming months and years

Outcomes of the UN High-level Meeting on NCDs

Objective 1 To raise the priority

accorded to the prevention and

control of NCDs in global, regional

and national agendas and

internationally agreed

development goals, through

strengthened international cooperation

and advocacy

Objective 2 To strengthen

national capacity, leadership,

governance, multisectoral

action and partnerships to

accelerate country response for the prevention

and control of NCDs

Objective 3 To reduce

modifiable risk factors for NCDs and underlying

social determinants through

creation of health-promoting

environments

Objective 4 To strengthen and

orient health systems to address the prevention and

control of noncommunicable

diseases and the underlying

social determinants through people-centred primary health care and universal health

coverage

Objective 5 To promote and support national capacity for high-quality research

and development for the prevention

and control of NCDs

Objective 6 To monitor the

trends and determinants of

NCDs and evaluate progress in their

prevention and control

Resolution WHA66.10 – Global NCD Action Plan 2013-2020

It comprises a set of actions which, when performed collectively by Member States, international partners and the WHO Secretariat, will attain 9 voluntary global targets for

NCDs by 2025

http://www.who.int/nmh/global_monitoring_framework/en/index.html

Technical support provided by WHO to Member States

National capacity assessments

Upstream policy advice to develop national multisectoral plans and policies for NCDs

Sophisticated technical support for NCDs (e.g. to develop tobacco tax legislation)

Set national targets and indicators

Articulate options for multisectoral action through national partnerships

Exchange best practices, lessons-learned

(based on a review of international experience)

What is the role of each stakeholder?

Ministry of Health officials and other stakeholders are encouraged to mobilize the whole-of-government, civil society, and health care professionals to integrate NCDs into the health-planning processes and development agenda.

Sector Tobacco Physical

inactivity

Harmful use of alcohol

Unhealthy diet

Agriculture

Communication

Education

Energy

Environment

Finance

Food

Health

Housing

Industry

Justice/Security

Legislature

Transport

Social/Welfare

Sports

Trade

Urban planning

Cross-sectoral government engagement to reduce risk factors

"This is the second health issue ever to be addressed at a special meeting of the United Nations General Assembly. We should all work to meet targets to reduce NCDs. WHO's best buys serve as excellent guidance"

Ban Ki-moon • UN Secretary-General • 19 September 2011

Why "best buys" for NCDs?

Public health and economic burden show the size of the problem, but not how to address

and reduce it

Cost-effectiveness indicates solutions but not their

feasibility, affordability, and acceptability

Need to develop:

(1) NCD "best buy" interventions that are cost-effective, feasible, low-cost

and appropriate to implement within the

constraints of the local health system

(2) Financial planning tool for identifying resource

needs

(3) Price tag analysis to inform global resource

mobilisation

“Best buys” identified by WHO (Cost-effective interventions)

The cumulative effect of tobacco control measures implemented at

the highest level of achievement is tremendous (2/2)

MPOWER tobacco control measures applied at the highest level of achievement in 41 countries from 2007-2010 will result in

15 million fewer smokers and will consequently avert 7.4 million premature deaths by 2050

Source: Levy, David T., et al. (July 2013) "Smoking-related deaths averted due to three years of policy progress."

Implementing low-cost workable solutions in developing countries could prevent most premature deaths from NCDs

2/3 + 1/3 Implementing cost-effective interventions that reduce

exposure of populations to risk factors for NCDs will contribute up to two-thirds of the reduction in premature mortality.

In addition, health systems that respond more effectively and equitably to the health-care needs of people with NCDs can reduce premature mortality by another one-third up to one-half.

US$ 170B is the overall cost for all developing countries to scale up action by implementing a set of "best buy" interventions between 2011 and 2025, identified as priority actions by WHO

US$ 7T is the cumulative lost output in developing countries associated with NCDs between 2011-2025

The cost of inaction in developing countries over the next 15 years is enormous (compared to the cost of action)

Reports are available at www.who.int/ncd

How are NCDs being integrated into the

global post-2015 development agenda discussions?

A global process is underway to determine the role of NCDs in the post-2015 development framework.

2010 MDG Summit

Rio+20 UN System Task Team

SG's High-level Panel of Eminent

Persons

Working Group on Sustainabl

e Development Goals

Adoption of the post-2015 UN

development agenda

Post-2015 process

“ We understand the goals of sustainable development can only be achieved in the absence of a high prevalence of debilitating communicable and NCDs, and where populations can reach a state of physical, mental and social well-being. ” (paragraph 138) “ We acknowledge that the global burden and threat of NCDs constitutes one of the major challenges for sustainable development in the twenty-first century. ” (paragraph 141)

Rio+20: "NCDs constitute one of the major challenges for sustainable development"

“ The MDGs did not adequately address … increase in NCDs . ” (paragraph 19) “ Priorities for social development and investments in people would include: … NCDs. Access to sufficient nutritious food and promotion of healthy life styles with universal access to preventive health services will be essential to reduce the high incidence of NCDs diseases in both developed and developing countries” (paragraph 67)

UN System Task Team on the post-2015 UN development agenda: NCDs is a priority for social development and investments in people

SG's High-level Panel of Eminent Persons on the post-2015 UN development agenda

Co-Chair: Susilo Bambang Yudhoyono President of Indonesia

Co-Chair: Ellen Johnson Sirleaf President of Liberia

Co-Chair: David Cameron Prime Minister of the UK

Benin Brazil China Colombia Cuba France Germany Japan

Jordan Kenya India Latvia Mexico Netherla

nds Nigeria

Russian Fed

South Africa

Rep Korea

Sweden Timor-Leste

Turkey USA Yemen Ex Officio

• Mandate: MDG+10 Summit • Output: SG delivers a report to UNGA by the 2nd quarter of 2013 • Input: Work based on report of UN System Task Team • Work to be informed by Rio+20 and UNDG's consultations

CEO Unilever

Fram

ewo

rk • 12 universal goals and

54 national targets

• Goal 4: Ensure healthy lives

• Target: 4e. Reduce burden of priority NCDs

Stre

ngt

hs • Focus on most

vulnerable

populations

• Health as a key dimension of

poverty, contributor to

development

• Call for a “data revolution”

We

akn

ess

es • Health framed as

“basic need”

instead of fundamental right

• Weak definition of NCDs

• Lack of recognition as a

development issue

• Weak on prevention / omission of

major NCD risk factors

UN High-Level Panel Report to the Secretary-General, May 2013 Highlights

Major UN events to solidify the Post-2015 development agenda

• UN High-Level Meeting on Disability and Development (HLMDD) – Monday 23 September • Inaugural Meeting of the High-level Political Forum (HLPF) on Sustainable Development – Monday 23 September • Opening of the general debate of the 68th Session of the UN General Assembly – Tuesday 24 September • Special Event on Millennium Development Goals (MDGs) – Wednesday 25 September

Key messages

1. An epidemiological transition is shifting the primary global burden of disease from communicable to noncommunicable diseases.

2. Developing countries now face a double burden of disease. 3. NCDs undermine the Millennium Development Goals, and

disproportionately affect developing countries. 4. The four main risk factors for NCDs also influence the outcomes

of communicable diseases such as HIV and TB outcomes, along with other health areas such as maternal and child health.

5. The Global Action Plan outlines the commitment of WHO Member States to comprehensively addressing NCDs.

6. ‘Best buys’ are available to assist countries to combat NCDs efficiently and effectively.

7. A process is underway to determine the role of NCDs in the post-2015 development agenda.

Thank you bettcherd@who.int